Antimicrobial resistance is one of the greatest public health threats worldwide. The development and proliferation of multidrug-resistant pathogens is largely driven by inappropriate antimicrobial use. Current reports state that over 50% of antimicrobial use in hospitals and up to 70% in long-term care facilities is potentially inappropriate. Recognizing the urgency of this national crisis, President Obama issued an executive order in September 2014, mandating the implementation of antimicrobial stewardship programs (AMS) nationally, and specifically noting that ?all VA healthcare settings, including long-term care facilities? will be involved. Unfortunately, this process of developing AMS in VA Community Living Centers has lagged behind those in acute-care facilities and little is known about the degree of antibiotic resistance and the types of stewardship interventions that might work in these facilities. Antimicrobial stewardship promotes the appropriate use of antimicrobials in order to improve patient safety and to decrease adverse events related to inappropriate antimicrobial use. Improving antimicrobial use in acute-care facilities is a critical focus of The Veterans Health Administration (VHA), as evidenced by the recent VHA Directive 1031. This policy charges every Veterans Affairs (VA) acute care facility to develop and implement an antimicrobial stewardship program led by champion physicians and pharmacists. This VHA Directive does not currently require the implentation of antimicrobial stewardship activities within nursing homes. In 2013, the VHA provided care to over 100,000 veterans in nursing homes. This proposal brings together a cadre of VA experts in the fields of long term care quality improvement, infectious diseases, geriatrics, and antibiotic stewardship (MDs, PharmDs, PhD) to directly address this timely area of study. In direct response to an HSRD priority area for research involving long term care, the overall goals of this 4 year mixed methods merit proposal are to determine the scope of antimicrobial resistance among VA CLCs, to compare that information with antimicrobial utilization patterns in CLCs and proximal VAMCs, and to develop effective antimicrobial stewardship strategies tailored for the long term care environment. We hypothesize that resistance patterns and antibiotic use for CLCs will vary significantly and will be different from those observed in proximal acute care facilities. Furthermore, we hypothesize that comprehensive interdisciplinary antimicrobial stewardship programs will have the capacity to reduce selection for drug-resistant pathogens for the CLC, minimize transmission of antimicrobial-resistant pathogens among patients, and ultimately improve clinical outcomes provided that they are tailored to the unique barriers that long term care entails. The specific aims of this study are: 1) Measure antimicrobial use and resistance in VA-CLCs nationally through the development of a longitudinal database of antimicrobial use and resistance. This database would allow us to quantify regional and temporal trends, and identify areas of high antimicrobial use and resistance nationally, 2) Develop and implement various well researched antimicrobial stewardship practices and programs at three CLCs, 3) Measure Antimicrobial Stewardship interventions on resistance, antimicrobial use and outcomes data from pilot CLCs.